Provider Demographics
NPI:1336104637
Name:WILLIAMS, LYNORE S (CTRS)
Entity Type:Individual
Prefix:
First Name:LYNORE
Middle Name:S
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MARVIN RD
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-1913
Mailing Address - Country:US
Mailing Address - Phone:860-537-2136
Mailing Address - Fax:
Practice Address - Street 1:150 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2003
Practice Address - Country:US
Practice Address - Phone:860-646-1222
Practice Address - Fax:860-647-6829
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11198174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT11198OtherCERTIFIED THERAPEUTIC REC